Preferred Administrators Preventive Services FISCAL YEAR 2018 Effective October 1, 2017

Transcription

1 Effective October 1, 2017 Preventive Service: (Fiscal Year starts 10/1-9/30) Abdominal aortic aneurysm screening: men one-time screening for abdominal aortic aneurysm by ultrasonography in men aged 65 to 75 who have ever smoked. CPT Code(s): ICD10 Diagnosis Code(s) Z00.00, Z00.01, Z00.8, Z72.0, Z87.891, F F Alcohol misuse counseling screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings. G0442, G , F10.10-F10.99, O09.70, O09.71, O09.72, O09.73, O09.891, O09.892, O09.893, O09.899, O O Z33.1, Z00.00, Z00.01, Z00.8, Z13.89, Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, Z71.41 *This benefit can be billed also with any ICD10 pregnancy diagnosis listing on page 30. Page 1

2 Anemia screening: pregnant women. routine screening for iron deficiency anemia in asymptomatic pregnant women , 85014, 85018,36415, Z00.00, Z00.01, Z00.8, Z13.0 *This benefit can be billed also with any ICD10 pregnancy diagnosis listing on page 30. Aspirin to prevent CVD: men the use of aspirin for men age 45 to 79 years when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage 99386,99387, 99396,99397, Z00.00, Z00.01, Z00.8 Aspirin to prevent CVD: women the use of aspirin for women age 55 to 79 years when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage. Bacteriuria screening: pregnant women. screening for asymptomatic bacteriuria with urine culture for pregnant women at 12 to 16 weeks gestation or at the first prenatal visit, if later ,99387, 99396,99397, , 87088, Z00.00, Z00.01, Z00.8 Z00.00, Z01.411, Z01.419, Z13.89 *This benefit can be billed also with any ICD10 preventive diagnosis listing on page 30. Page 2

3 Blood pressure screening screening for high blood pressure in adults aged 18 and older , , Z00.00, Z00.01, Z00.8, Z13.6 R03.0 BRCA Lab Screening and Genetic Counseling and Evaluation for BRCA Testing; that primary care providers screen women who have family members with breast, ovarian, tubal, or peritoneal cancer with one of several screening tools designed to identify a family history that may be associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA1 or BRCA2). Women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing , , 81162, 81432, 81433, , , G0463, 96040, S0265, 36415, All BRCA Labs require a prior-authorization Z31.5, Z13.79, Z80.3, Z80.41, Z85.3, Z85.43, Z15.01, Z15.02 Z80.41 Page 3

4 Breast cancer preventive medication The USPSTF recommends that clinicians discuss chemoprevention with women at high risk for breast cancer and at low risk for adverse effects of chemoprevention. Clinicians should inform patients of the potential benefits and harms of chemoprevention. Breast cancer screening The USPSTF recommends screening mammography for women, with or without clinical breast examination, every 1-2 years for women aged 40 and older Z00.00, Z00.01, Z00.8, Z01.411, Z01.419, Z15.01, Z80.3, Z85.3 G0202, G0206, G0204, G0279, 77065, 77063, 77066, Revenue Code 0403 Z01.411, Z01.419, Z12.31, Z12.39 Page 4

5 Breastfeeding Support, Supplies, and Counseling interventions during pregnancy and after birth to promote and support , , 99341, , A4281, A4286, E E0603, Z01.411, Z01.419, Z39.1 Z71.89, O92.70, O92.79 The purchase of a portable double electric pump (non-hospital grade) A purchase will be covered once every five years following the date of the birth. If a portable double electric pump was purchased within the previous period, the purchase of a portable double electric pump will not be covered until a five year period has elapsed from the last purchase of an electric pump. The purchase of an manual breast pump A purchase will be covered once every five years following the date of the birth. If a manual pump was purchased within the previous period, the purchase of a manual pump will not be covered until a five year period has elapsed from the last purchase of an electric pump. Breast Pump Supplies Coverage is limited to only one per pregnancy in a year where a covered female would not qualify for the purchase of a new pump. Coverage for the purchase of breast pump equipment is limited to one item of equipment for the same or similar purpose, and the accessories and supplies needed to operate the item. The covered Associate or its dependent is responsible for the entire cost of any additional same or similar equipment that is purchased or rented for personal convenience or mobility. Page 5

6 Breast Pump Reimbursement Note if provider is submitting for reimbursement Pre-Auth will be required for all electric and manual breast pumps. We have reimbursement fees for these services, therefore, an invoice is required. Reimbursement will be coordinated between Case Management, Contracting, and the DME Provider. Note if member is submitting for reimbursement: Effective 12/1/13, members can submit a member reimbursement for the purchase of a portable double electronic non-hospital grade breast pump. Preferred Administrators will reimburse for a breast pump up to $ dollars or up to $50.00 dollars for supplies. These items can be purchased at any retailer or pharmacy. Member will be reimbursed when they have submitted the following: Member Reimbursement Form This form can be downloaded at Receipt Prescription form OB Provider The TPA Department will review that the Member Reimbursement Form and attachments are complete, sign and take to Claims for processing. Page 6

7 Cervical cancer screening The USPSTF strongly recommends screening for cervical cancer in women who have been sexually active and have a cervix , , , , ,G0101, G0123 G0124, G0141, G G0145, G G0148, Q0091 Z00.00, Z00.01, Z01.411, Z01.419, Z01.42, Z12.4, Z12.72 Chlamydia infection screening: non-pregnant women screening for chlamydia infection for all sexually active non-pregnant young women age 24 and younger and for older non-pregnant women who are at increased risk , 87110, 87270, 87320, , 87810, Z00.00, Z00.01, Z00.8, Z01.411, Z01.419, Z11.3, Z11.8, Z11.9, Z20.2 Chlamydia infection screening: pregnant women screening for Chlamydia infection for all pregnant women age 24 and younger and for older pregnant women who are at increased risk , 87110, 87270, 87320, , 87810, Z00.00, Z00.01, Z00.8, Z01.411, Z01.419, Z11.3, Z11.9, Z20.2 Z11.8 *This benefit can be billed also with any ICD10 pregnancy diagnosis listing on page 30. Page 7

8 Cholesterol abnormalities screening: men 35 and older The USPSTF strongly recommends screening men aged 35 and older for lipid disorders , Z00.00, Z00.01, Z00.8, Z Cholesterol abnormalities screening: men younger than 35 screening men aged 20 to 35 for lipid disorders if they are at increased risk for coronary heart disease , Z00.00, Z00.01, Z00.8, Z Cholesterol abnormalities screening: women 45 and older The USPSTF strongly recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease , Z00.00, Z00.01, Z00.8, Z Page 8

9 Cholesterol abnormalities screening: women younger than 45 screening women aged 20 to 45 for lipid disorders if they are at increased risk for coronary heart disease , 82465, Z00.00, Z00.01, Z00.8, Z Cholesterol screening (dyslipidemia): children/adolescents ages 24 months - 21 years 80061, 82465, Z00.00, Z00.01, Z00.121, Z Z13.220, Z00.8 Page 9

10 Colorectal cancer screening screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods vary. ** Colorectal Cancer Screening is restricted to primary diagnosis and claim will pay as preventive if billed with primary diagnosis listed. If preventive diagnosis is not billed as primary, the claim will process as medical and member will have cost share. **Colorectal Cancer Screenings are only for adults beginning at age 50 years and continuing until age 75. G G0106 G G0122, 45330, 45331, 45346, 45378, 45380, 45385, 45388, 44392, 44394, 74263, 82270, 82274, G0328, G0464, S0285, 82270, 82274, 88304, Requires Prior Authorization except for codes 74263, 82270, 82274,81528 G0328, G0464 Anesthesia Sedation 99152, 99153, 99156, 99157, G0500 Revenue Codes 0750, 0490, , Z00.00, Z00.01, Z00.8, Z12.10, Z12.11, Z12.12, Z12.13, Z80.0, Z83.79 Page 10

11 Note: ICD-10 codes are effective 10/1/15 Contraceptive methods to include sterilization and Contraceptive Counseling. All Contraceptive methods, services, and supplies covered must be approved by the Food and Drug Administration (FDA). Coverage includes counseling services on contraceptive methods provided by a Physician, Obstetrician or Gynecologist. Covered Contraceptive to include Female Generic Prescription Drugs are covered. All IUDs are covered by the Medical Plan to include its insertion and removal. Please refer to the list of female generic medications posted online. These medications are reimbursed by our RX Pharmacy Vendor (NAVITUS). Visits , , , , Sterilizations , , , 58340, 74740, Q9967 A4264 Anesthesia for Sterilization 00851, 00940, 00942, 00950, 00952, 01960, 01961, 01965, 01966, Labs Z30.011, Z30.012, Z30.013, Z30.014, Z30.018, Z30.019, Z30.02, Z30.09, Z30.2, Z30.40, Z30.41, Z30.42, Z30.430, Z30.431, Z30.432, Z30.433, Z30.49, Z30.8, Z30.9 Page 11

12 Contraceptive methods to include sterilization and Contraceptive Counseling. All Contraceptive methods, services, and supplies covered must be approved by the Food and Drug Administration (FDA). Diaphragm or Cervical Cap Covered under Navitus Pharmacy RX Vendor A4267 IUDs J7300, J7301, J7297, J7298 Insertion and Removal covered under Medical 58300, Implantable Devices J7306, J7307 Insertion and Removal covered under Medical Nexplanon Insertion and Removal with reinsertion A4264 Depo-provera Injections J1050, J (Administration covered under Medical) Revenue codes , , , 0490 Sterilization for men , All supplies, including anesthetizing agents, inhalants, surgical trays, or dressings are included in the surgical payment on the day of surgery when the surgery is performed in the office. Z30.2 Page 12

13 Preventive Service: CPT Code(s): ICD10 Diagnosis Code(s) Dental caries prevention: preschool children fluoride varnish for all infants and children starting at age of primary tooth eruption; oral fluoride supplementation starting at age 6 months for children whose water supply is fluoride deficient Z00.121, Z00.129, Z41.8 Depression screening: adolescents screening of adolescents (12-18 years of age) for major depressive disorder when systems are in place to assure accurate diagnosis, psychotherapy (cognitivebehavioral or interpersonal), and follow-up , , , Z13.89, Z13.4 Page 13

14 Depression screening: adults screening adults for depression when staffassisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up Z13.89 Developmental Screening and Emotional Behavioral Assessment for ages 21 and under Diabetes screening screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg. Dyslipidemia Screening 24 months to 21 years , 82962, , Z00.121, Z Z00.00, Z00.01, Z00.8, Z13.1 Z00.121, Z00.129, Z Folic acid supplementation that all women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 μg) of folic acid. Reimbursed by Pharmacy Vendor (NAVITUS) Page 14

15 Gestational diabetes Screening in pregnant women gestational diabetes screening in pregnant women between 24 and 28 weeks of gestation and at the first prenatal visit for pregnant women identified to be at high risk for diabetes , 82962, Z00.00, Z00.01, Z00.8, Z13.1 *This benefit can be billed also with any ICD10 pregnancy diagnosis listing on page 30. Gonorrhea prophylactic medication: newborns The USPSTF strongly recommends prophylactic ocular topical medication for all newborns against gonococcalophthalmiane onatorum. Reimbursed by Pharmacy (NAVITUS) Page 15

16 Gonorrhea screening: women that clinicians screen all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk for infection (that is, if they are young or have other individual or population risk factors). Healthy diet counseling intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and dietrelated chronic disease. Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians , 87801, Z00.00, Z00.01, Z00.8, Z01.411, Z01.419, Z11.3, Z11.9 *This benefit can be billed also with any ICD10 pregnancy diagnosis listing on page 30. Z71.3, Z Z68.54, Z13.9, Z13.21, Z13.220, Z13.228, Z00.00, Z00.01, Z00.8, E E78.5 Page 16

17 Loss screening: newborns The USPSTF recommends screening for hearing loss in all newborn infants , 92552, Z13.5, Z00.110, Z00.121, Z Hemoglobinopathies screening: newborns The USPSTF recommends screening for sickle cell disease in newborns. Hepatitis C screening Recommends screening for everyone ages 15-65, and other ages at increased risk , 83026, , 86804, G0472, 36415, Z00.110, Z00.121, Z00.129, Z13.0, Z84.81 Z11.9, Z11.59 Page 17

18 Preventive Service: CPT Code ICD10 Diagnosis Code(s) HIV screening Strongly recommends that clinicians screen for human immunodeficiency virus (HIV) for everyone ages 15-65, and other ages at increased risk for HIV infection , G G0435, G0475, 86689, , S3645, 36415, 87389, 87390, Z20.2 Z00.00, Z00.01, Z00.8, Z11.3, Z11.4, Z11.59, Z11.9, Z20.6 *This benefit can be billed also with any ICD10 pregnancy diagnosis listing on page 30. Page 18

19 Human papillomavirus testing (HPV) The USPSTF recommends screening for high-risk human papillomavirus DNA testing in women with normal cytology results. Screening should begin at 30 years of age and should occur no more frequently than every 3 years G0476, Z00.00, Z00.01, Z00.8, Z01.411, Z01.419, Z11.51, Z12.4 Hypothyroidism screening: newborns The USPSTF recommends recommends screening for congenital hypothyroidism in newborns. Interpersonal and domestic violence screening and counseling The USPSTF recommends screening and counseling for interpersonal and domestic violence. Coverage for PCP, LPC and LSW , Z00.110, Z00.111, Z13.29 Z69.11, Z69.12, Z69.11-Z69.82 Page 19

20 Iron Supplementation in children The USPSTF recommends routine iron supplementation for asymptomatic children aged 6 to 12 months who are at increased risk for iron deficiency anemia. Lung cancer screening. USPSTF recommends annual screening for lung cancer with lowdose computed tomography in adults ages 55 to 80 years who have a 30 packyear smoking history and currently smoke or have quit within the past 15 years. Newborn metabolic screening panel D50.0, D50.8, D50.9, E61.1 G G0297 S3620, 82775, 83498, F17.210, F17.211, F17.213, F17.218, F17.219, Z12.2, Z Z00.110, Z Page 20

21 Obesity screening and counseling: adults that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults. Obesity screening and counseling: children that clinicians screen children aged 6 years and older and offer them or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status. Osteoporosis screening for women age 50 years and older. Frequency is every two years , 77078, 77080, 77081, G0130 Revenue Codes Z13.89, Z71.3, Z68.1-Z68.54 Z13.89, Z71.3, Z68.1-Z68.54 Z00.00, Z00.01, Z00.8, Z13.820, Z82.62 Page 21

22 Routine preventive visits will now be covered as stated by the American Academy of Pediatrics Periodicity Table. The frequency of visits for children and adolescents will be according to American Academy of Pediatrics as follows: newborn, 3-5 days, 1 months, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 24 months, 30 months, 3 years - 21 years. Preventive Annual/ Physical Exams for Male/Female: Age Group- 0-1 year Preventive Annual/ Physical Exams for Male/Female: Age Group- 1-4 years 99381, , Z76.2, Z00.121, Z00.129, Z00.110, Z Z76.2, Z Z Preventive Annual/ Physical Exams for Male/Female: Age Group years 99383, Z76.2, Z Z Page 22

23 Preventive Annual/ Physical Exams for Male/Female: Age Group years Preventive Well Child Labs for 21 years of age and younger Routine Immunizations and Administration of Vaccines for Children and Adult *The following Codes have been discontinued effective January 1, , 90646, 90669, 90692, 90693, 90703, 90704, 90705, 90706, 90708, 90712, 90719, 90720, 90721, 90725, 90727, , Z76.2, Z Z , 82247, 88720, 80061, 82465, 83718, 84478, 85018, 83655, *Administration Codes 90460, 90461, 90471, 90474, 90472, Admin Revenue Code Vaccines Codes , , , 90653, Q2035, Q2037, Q2038 Z00.00, Z00.01, Z00.8, Z13.228, Z13.220, Z13.0, Z13.88, Z11.1 Z76.2, Z23, Z00.129, Z00.121, Z00.110, Z00.00, Z00.01, Z00.8 Routine preventive visits will now be covered as stated by the American Academy of Pediatrics Periodicity Table. The frequency of visits for children and adolescents will be according to American Academy of Pediatrics as follows: newborn, 3-5 days, 1 months, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 24 months, 30 months, 3 years - 21 years. Comprehensive preventive medicine evaluation and management of an individual includes: An age and gender-appropriate history Physical examination Counseling/anticipatory guidance Risk factor reduction interventions The ordering of appropriate immunization(s) and laboratory/ screening procedures Routine hearing Routine vision Preventive routine hearing exams (CPT Code 92551) and vision exams (99173) will now be covered as part of the routine preventive visits, to include children and adolescents. Page 23

24 Preventive Annual Physical Exams for Male/Female: Age Group age This would include Well Adult Visit (Physicals) (One per Fiscal Year) Preventive Annual Physical Exams for Male/Female: Age Group age This would include Well Adult Visit (Physicals) (One per Fiscal Year) Preventive Annual Physical Exams for Male/Female: Age Group- 65- older This would include Well Adult Visit (Physicals) (One per Fiscal Year) 99385, Z00.00, Z00.01, Z00.8 Z00.00, Z00.01, Z00.8 Z00.00, Z00.01, Z00.8 Preventive Well Women Annual Visits with OB/GYN (One per Fiscal Year) , Z01.411, Z01.419, Z01.42, Z12.4 Page 24

25 Prostate Cancer Screening for men age 40 and older G G0103, 36415, Z00.00, Z00.01, Z12.5, Z80.42 Rh incompatibility screening: first pregnancy visit The USPSTF strongly recommends Rd (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care. Rh incompatibility screening: weeks gestation repeated Rh (D) antibody testing for all unsensitized Rh (D)-negative women at weeks gestation, unless the biological father is known to be Rh (D)-negative , 36415, Z01.411, Z01.419, Z13.0, Z01.83 *This benefit can be billed also with any ICD10 pregnancy diagnosis listing on page , 36415, Z01.411, Z01.419, Z01.83, Z3A.24 Z3A.28, Z13.0 Rubella Screening by Serology: for all women of childbearing age at their first clinical encounter , Z00.00, Z11.59, Z20.4 Page 25

26 STIs counseling highintensity behavioral counseling to prevent sexually transmitted infections (STIs) for all sexually active adolescents and for adults at increased risk for STIs. Syphilis screening: nonpregnant adults The USPSTF strongly recommends that clinicians screen persons at increased risk for syphilis infection Z00.00, Z00.01, Z00.8, Z70.0-Z , Z00.00, Z00.01, Z00.8, Z01.411, Z01.419, Z11.3, Z11.9 *This benefit can be billed also with any ICD10 preventive diagnosis listing on page 30. Syphilis screening: pregnant women that clinicians screen all pregnant women for syphilis infection , Z00.8, Z01.411, Z01.419, Z11.3, Z11.9, *This benefit can be billed also with any ICD10 pregnancy diagnosis listing on page 30. Page 26

27 Tobacco use counseling: non-pregnant adults that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. Tobacco use counseling: pregnant women that clinicians ask all pregnant women about tobacco use and provide augmented, pregnancytailored counseling to those who smoke. Tuberculosis infection screening: Adult 18 years and up Z00.00, Z00.01, Z Z00.00, Z00.01, Z00.8, Z71.6, O O99.335, F F17.299, Z , 36415, 71020, R76.11, R76.12, Z00.00, Z00.01, Z11.1, Z20.1 Page 27

28 Urinary tract or other infection screening: pregnant women , 36415, O O23.90, O23.01-O23.23, O23.31-O23.33, O23.41-O23.43, O O23.593, O23.91-O23.93, Z11.8, Z11.9 *This benefit can be billed also with any ICD10 pregnancy diagnosis listing on page 30. Page 28

29 Visual acuity screening in children screening to detect amblyopia, strabismus, and defects in visual acuity in children younger than age 5 years , 99174, 99177, Z00.110, Z00.121, Z00.129, Z01.00, Z01.01 Page 29

30 Pregnancy List O O09.93 O O30.93 Z Z34.93 O36.80X0 - O36.80X9 Z33.1 ICD10 Pregnancy List Page 30

31 Indications for Coverage Introduction: Effective for plan years on or after September 23, 2010, the federal Patient Protection and Affordable Care Act (PPACA) requires non-grandfathered health plans to cover certain recommended preventive services identified by PPACA under the Preventive Care Services benefit, without cost sharing to enrollees when provided by Network physicians. For Plan Years that on or after September 23, 2010: For non-grandfathered health plans, Preferred Administrators will cover the recommended preventive services under the Preventive Care Services benefit as mandated by PPACA, with no cost sharing when provided by a Network provider. These services are described in the United States Preventive Services Task Force A and B recommendations, the Advisory Committee on Immunization Practices (ACIP) of the CDC, and Health Resources and Services Administration (HRSA) Guidelines including the American Academy of Pediatrics Bright Futures periodicity guidelines. For Plan Years that on or after August 1, 2012: For non-grandfathered plans, Preferred Administrators will cover for women the additional preventive care and screenings as required by the HHS Health Plan Coverage Guidelines for Women s Preventive Services for plan years that begin on or after August 1, REFERENCES 1. Grade Definitions for USPSTF Recommendations 2. Women s Preventive Services: Required Health Plan Coverage Guidelines: 3. Department of Labor: 4. July 19, 2010 IRS Interim Rules: 5. American Academy of Pediatrics / Bright Futures / Recommendations for Pediatric Preventive Healthcare. (For ages 0 21): 6. American Academy of Pediatrics: Centers for Disease Control and Prevention / Immunization Schedules: 7. American Academy of Family Physicians (AAFP) Summary of Recommendations for Clinical Preventive Services: Page 31

32 GUIDELINE HISTORY/REVISION HISTORY This Preventive Listing will be updated accordingly to AMA/CPT updates. All updates will be posted at For a complete listing of benefits, you can review all Plan Documents and Summary of Benefits at For verification of eligibility and benefits, you can reach our Member Services Department at or if outside of the calling area. Member Services is available Monday through Friday from 7 a.m. to 5 p.m., Mountain Time. Effective Action/Revision Description Date of Change 10/2010 Original Effective Date of Preventive Service Listing. 1/1/2015 The following Codes have been discontinued effective 12/31/14. Codes discontinued and replaced with 87623, 87624, /3/15 Colorectal cancer screening Added Code G0464 1/11/16 The following Codes have been discontinued effective January 1, , 90646, 90669, 90692, 90693, 90703, 90704, 90705, 90706, 90708, 90712, 90719, 90720, 90721, 90725, 90727, 90735, J7302 1/11/16 Contraceptive Methods: Code J7302 have been replaced with codes J7297 and J7298 3/1/16 Developmental Screening: Added Code 96110, effective date is 10/1/15 Covered as a preventive screening for children 0-3 years of age 3/1/16 Breast Cancer Screening: Added Codes G0204, 77063, and G0279. Codes are effective 10/1/15 10/1/16 Abdominal aortic aneurysm screening: Added Z87.891, F17.10-F17.219, Z72.0 Removed G0389, 76705, and Added: (new code effective 1/1/17) 10/1/16 Alcohol misuse counseling: Added Z71.41, O99.10 O99.315, F F /1/16 Aspirin To Prevent CVD: Removed Z and Z Page 32

33 10/1/16 Aspirin to Prevent CVD In Women- Removed 85013, 85014, 85018, Z00.121, and Z Added , /1/16 Bacteriuria screening pregnant women: Added code 81007, Z /1/16 Blood Pressure Screening: Removed Z and Z /1/16 BRCA Lab Screening: Added 81432, Z31.5, Z13.79 Removed Removed Z /1/16 Breast cancer preventive medication: Added Z /1/16 Breast cancer screening: Added code G0206, 77065, 77066, (new code effective 1/1/17) Removed Z and Z /1/16 Breastfeeding Support, Supplies, and Counseling. Added codes 99341, Added ICD 10 O92.70, O92.79, Z /1/16 Chlamydia Infection Screening: Added ICD10 Z11.3, Z11.9, Z /1/16 Colorectal Cancer Screening: Added codes 45346, 45388, S0285, 00810, 00740, 81528, G0328, and G0464. Added ICD 10 Z83.79 Added Revenue Codes /1/16 Contraceptive methods to include sterilization and Contraceptive Counseling Added Codes 58340, 74740, A4264 and Q9967 Added Anesthesia Codes for Sterilization 00851, 00940, 00942, 00950, 00952, 01960, 01961, 01965, Added Revenue Codes for Sterilization , , , and 0490 Re listed Contraceptives by Categories Removed Codes , 11975, 11976, Removed ICD10 Z /1/16 Cholesterol abnormalities screening: women younger than 45 Added /1/16 Depression screening adolescents: Added Added Z13.4 Removed , , /1/16 Depression screening adults: Removed , , Page 33 Genetic Counseling and Evaluation for BRCA Testing; and BRCA Lab Screening Added code 81162

34 10/1/16 Healthy diet counseling: Added Z13.9, Z13.21, Z13.220, Z /1/16 Hepatitis C Screening: Added Z11.9, Z11.59 Removed the following ICD10 A51.46, A51.49, A51.5, A51.9, A52.00, A52.01, A52.02, A52.03, A52.04, A52.05, A52.06, A52.09, A52.10, A52.11, A52.12, A52.13, A52.14, A52.15, A52.16, A52.17, A52.19, A52.2, A52.3,A52.71, A52.72, A52.73,A52.74,A52.75,A52.76,A52.77, A52.78,A52.79,A52.8,A52.9,A53.0, A53.9, A54.00, A54.01, A54.02, A54.03, A54.09,A54.1,A54.21,A54.22,A54.23, A54.24,A54.29, A54.30,A54.31,A54.32, A54.33,A54.39,A54.40,A54.41,A54.42,A54.43,A54.49,A54.5,A54.6, A54.81,A54.82,A54.83, A54.84,A54.85,A54.86,A54.89,A54.9,A55,A56.00,A56.01,A56.02,A56.09,A56.11, A56.19, A56.2, A56.3, A56.4, A56.8, A57, A58, A59.00, A59.01, A59.02, A59.03, A59.09, A59.8, A59.9, A60.00, A60.01, A60.02, A60.03, A60.04, A60.09, A60.1, A60.9, A63.0, A63.8, A64, A74.81, A74.89, A74.9, B07.8, B07.9, B20, B97.35, B97.7, D65, D66, D67, D68.0, D68.1, D68.2, D68.311, D68.312, D68.318, D68.32, D68.4, D68.8, D68.9, F11.20,F11.21,F11.220,F11.221,F11.222, F11.229,F11.23,F11.24, F11.250,F11.251,F11.259,F11.281,F11.282,F11.288,F11.29,F12.20,F12.21,F12.220,F12.221,F12.222,F ,F12.250,F12.251,F12.259,F12.280,F12.288,F12.29,F13.20,F13.21,F13.220,F13.221,F13.229,F ,F13.231,F13.232,F13.239,F13.24,F13.250,F13.251,F13.259,F13.26,F13.27,F13.280,F13.281,F ,F13.288,F13.29,F14.20,F14.21,F14.220,F14.221,F14.222,F14.229,F14.23,F14.24,F14.250, F14.251,F14.259,F14.280,F14.281,F14.282, F14.288,F14.29,F15.20,F15.21,F15.220,F15.221,F ,F15.229,F15.23,F15.24,F15.250,F15.251F ,F15.280,F15.281,F15.282,F15.288,F15.29,F16.20,F16.21,F16.220,F16.221,F16.229, F16.24, F16.250,F16.251,F16.259,F16.280,F16.283,F16.288,F16.29,F18.20,F18.21,F18.220,F18.221,F18.229,F 18.24,F18.250,F18.251,F18.259,F18.27,F18.280,F ,F18.29,F19.20,F19.21,F19.220,F19.221,F ,F19.229,F19.230,F19.231,F19.232,F19.239,F19.24,F19.250,F19.251,F19.259,F19.26,F19.2,7 F19.280,F19.281, F19.282,F19.288,F19.29, K50.00,K50.011,K50.012,K50.013,K50.014, K50.018, K50.019,K50.10,K50.111,K50.112,K50.113, K50.114,K50.118,K50.119,K50.80, K50.811,K50.812,K50.813,K50.814,K50.818,K50.819, K50.90,K50.91,K50.912,K ,K50.914,K50.918,K50.919,K51.20,K51.211,K51.212,K51.213,K ,K51.218,K51.219,K51.30,K51.311,K51.312,K51.313,K51.314,K51.318,K51.319,K51.40,K51.411,K ,K51.413,K51.414,K ,K51.419,K51.50,K51.511,K51.512,K51.513,K ,K51.518,K51.519, K51.80,K51.811,K51.812,K51.813,K51.814,K51.818,K51.819,K51.90,K51.911,K K51.913,K51.914,K51.918,K51.919,M02.30,M02.311,M02.312,M02.319,M02.321,M02.322, M02.329,M02.331,M02.332,M02.339,M02.341,M02.342,M02.349,M02.351,M02.352,M02.359,M ,M02.362,M02.369,M02.371,M02.372,M02.379,M02.38,M02.39,N18.3, N18.4,N18.5,N18.6,N34.1,N49.1,N49.2,N49.3,N49.8,N49.9,N73.5,N73.9,N76.0,N76.1,N76.2,N76.3,N7 7.1,O35.3XX0,O35.3XX1,O35.3XX2,O35.3XX3,O35.3XX4,O35.3XX5,O35.3XX9,O35.5XX0, O35.5XX1,O35.5XX2,O35. 5XX3,O35.5XX4,O35.5XX5,O35.5XX9,O90.4,O98.011,O98.012,O98.013,O ,O98.02,O98.03,O98.111,O98.112,O98.113,O98.119,O98.12,O98.13,O98.211,O98.212,O ,O98.219,O98.22,O98.23,O98.311,O98.312,O98.313,O98.319,O98.32,O98.33,O99.320,O99.321,O99.322,O99.323,O99.324,O99.325,P00.2, Page 34

35 Z00.00,Z00.01,Z04. 41,Z04.42,Z11.3,Z11.4,Z11.59,Z11.9,Z14.01,Z14.02,Z20.2,Z20.5,Z20.6,Z20.828,Z2 1,Z22.4,Z41.8,Z48.21,Z48.22,Z48.24,Z48.280,Z48.288,Z48.290,Z48.298,Z49.31,Z49.32,Z51.89,Z ,Z52.001,Z52.008,Z52.010,Z52.011,Z52.018,Z52.090,Z52.091,Z52.098,Z52.10,Z52.11,Z52.19,Z52.20,Z52.21,Z52.29,Z52.3,Z52.4,Z52.5,Z52.6,Z52.89, Z52.9,Z57.8,Z71.7,Z72.51,Z72.52,Z72.53,Z79.899,Z86.2,Z92.25,Z94.0,Z94.1,Z94.2,Z94.3,Z94.5,Z94.6, Z94.7, Z94.81,Z94.82,Z94.83,Z94.84,Z94.89,Z94.9,Z95.3,Z95.4,Z /1/16 HIV screening: Added code G0475. Added ICD10 Z20.2 Removed Z22.6, Z22.8, Z /1/16 Human papillomavirus testing (HPV): Added code G /1/16 Interpersonal and domestic violence screening: Removed R41.83, Z60.0, Z60.8, Z60.9, Z64.4, Z65.4, Z65.8, Z /1/16 Lung Cancer Screening: Added codes G0296- G /1/16 Obesity screening and counseling adults: Added Z71.3, Z68.1, Z /1/16 Obesity screening and counseling children: Added Z71.3, Z68.1 Z /1/16 Pregnancy ICD10 Listing corrected O to O and corrected ICD10 Range /1/16 Preventive Annual/Physical Exams Routine preventive visits will now be covered as stated by the American Academy of Pediatrics Periodicity Table. The frequency will now cover as stated below. Routine preventive visits will now be covered as stated by the American Academy of Pediatrics Periodicity Table. The frequency of visits for children and adolescents will be according to American Academy of Pediatrics as follows: newborn, 3-5 days, 1 months, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 24 months, 30 months, 3 years - 21 years. Preventive routine hearing exams (CPT Code 92551) and vision exams (99173) will now be covered as part of the routine preventive visits, to include children and adolescents. Codes and will be paid to provider according to contract. REMOVE- For children over 5 years, the hearing and vision exams are covered as medical and applicable deductibles or co-insurance will apply. REMOVE- The frequency of visits for children from 0-1 year are according to American Academy of Pediatrics as follows: 3-5 days, 1 month, 2 months, 4 months, 6 months, and 9 months) The frequency of visits for children 1-17 years is once per Fiscal Year. 10/1/16 Prostate Screening: Added codes G0102-G0103, , Added ICD 10 Z00.00, Z00.01, Z12.5, Z80.42 Page 35

36 10/1/16 Rh incompatibility screening: first pregnancy visit:- Added Added Z01.83 Removed Z36 Removed /1/16 Rh incompatibility screening: weeks gestation: Added Added Z01.83, Z3A.24 - Z3A.28 Removed Z36 Removed /1/16 Routine Immunizations and Administration of Vaccines for Children and Adult Added Q2035, Q2037, Q /1/16 Syphilis screening: pregnant women: Added Removed /1/16 STIs counseling: Added Z70.0 Z70.9 Removed Z71.89, /1/16 Syphilis Screening: Added Removed /1/16 Tobacco use counseling: pregnant women Added Z00.00, Z00.01, Z71.6, Z72.0, O O99.335, F F Removed Note: This benefit can be billed also with any ICD10 pregnancy diagnosis listing on page /1/16 Urinary Tract: Added Added Z11.8, Z11.9 Removed Z O23.513, O O23.523, O86.11 O86.29 Removed /1/16 Visual acuity screening in children. Added codes and /1/16 Removed all ICD9 diagnosis codes 1/1/17 Breast Cancer Screening: Added 77065, 77066, Removed 77051, 77052, 77055, 77056, and /1/17 Anemia screening: pregnant women: Removed /1/17 Blood pressure screening: Added R /1/17 BRCA Lab Screening and Genetic Counseling and Evaluation for BRCA Testing: Added Z /1/17 Cholesterol abnormalities screening men 35 and older: Removed 83718, 83719, and /1/17 Cholesterol abnormalities screening: men younger than 35: Removed 83718, 83719, and Page 36

37 10/1/17 Cholesterol abnormalities screening women 45 and older: Removed 83718, 83719, and /1/17 Cholesterol abnormalities screening women younger than 45: Removed 83718, 83719, and /1/17 Cholesterol screening (dyslipidemia): children/adolescents ages 24 months - 21 years: Added 80061, 82465, ICD 10 Codes Z00.00, Z00.01, Z00.121, Z Z13.220, Z /1/17 Colorectal cancer screening: Added 45331, 44392, 44394, 82270, 82274, 88304, 88305, 99152, 99153, 99156, 99157, G /1/17 Dental Caries Prevention: Added 99188, ICD 10 Z00.121, Z00.129, Z /1/17 Dyslipidemia Screening 24 months to 21 years: Added 80061, 82465, ICD 10 Z00.121, Z00.129, Z /1/17 Hemoglobinopathies screening newborns : Added /1/17 Hepatitis C screening : Removed /1/17 HIV Screening: Added 87389, 87390, /1/17 Hypothyroidism screening newborns: Added /1/17 Lung Cancer Screening: Code S8032 terminated 12/31/16 10/1/17 Newborn Metabolic Screening Panel: Added S3620, 82775, 83498, Added ICD 10 Z00.110, Z /1/17 Prostate Cancer Screening for men age 40 and older: Removed /1/17 Rubella Screening by Serology: Added 86762, Added ICD10 Z00.00, Z11.59, Z /1/17 Tuberculosis Infection Screening: Added 86580, 36415, 71020, Added ICD 10 R76.11, R76.12, Z00.00, Z00.01, Z11.1, Z /1/17 Sterilization for men: Added /1/17 Added Preventive Well Child Labs for 21 years of age and younger Page 37